The Impact of Health Literacy–Sensitive Design and Heart Age in a Cardiovascular Disease Prevention Decision Aid: Randomized Controlled Trial and End-User Testing

Abstract

Background Shared decision-making is an essential principle for the prevention of cardiovascular disease (CVD), where asymptomatic people consider lifelong medication and lifestyle changes. Objective This study aims to develop and evaluate the first literacy-sensitive CVD prevention decision aid (DA) developed for people with low health literacy, and investigate the impact of literacy-sensitive design and heart age. Methods We developed a standard DA based on international standards. The standard DA was based on our existing general practitioner DA. The literacy-sensitive DA included simple language, supporting images, white space, and a lifestyle action plan. The control DA used Heart Foundation materials. A randomized trial included 859 people aged 45-74 years using a 3 (DA: standard, literacy-sensitive, control) ×2 (heart age: heart age + percentage risk, percentage risk only) factorial design, with outcomes including prevention intentions and behaviors, gist and verbatim knowledge of risk, credibility, emotional response, and decisional conflict. We iteratively improved the literacy-sensitive version based on end-user testing interviews with 20 people with varying health literacy levels. Results Immediately after the intervention (n=859), there were no differences in any outcome among the DA groups. The heart age group was less likely to have a positive emotional response, perceived the message as less credible, and had higher gist and verbatim knowledge of heart age risk but not percentage risk. After 4 weeks (n=596), the DA group had better gist knowledge of percentage risk than the control group. The literacy-sensitive DA group had higher fruit consumption, and the standard DA group had better verbatim knowledge of percentage risk. Verbatim knowledge was higher for heart age than for percentage risk among those who received both. Conclusions The literacy-sensitive DA resulted in increased knowledge of CVD risk and increased fruit consumption in participants with varying health literacy levels and CVD risk results. Adding heart age did not increase lifestyle change intentions or behavior but did affect psychological outcomes, consistent with previous findings. This tool will be integrated with additional resources to improve other lifestyle outcomes. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12620000806965; https://tinyurl.com/226yhk8a

The Impact and Perception of England’s Web-Based Heart Age Test of Cardiovascular Disease Risk: Mixed Methods Study

“…If an individual has ≥1 risk factors (ie, cholesterol level and blood pressure) that are less than optimal, their heart age will be higher than their chronological age. There is evidence that use of heart age improves risk perception and recall and is more emotionally impactful [10][11][12][13][14][15][16][17][18][19][20][21][22], compared with other risk communication methods, such as percentage risk scores.…”

What makes an action plan “100% me”? Think aloud interviews about CVD prevention tools for varying health literacy needs

“…[15][16][17][18][19][20][21] This type of plan is well suited to online formats 14,[22][23][24] which allows for easy distribution, scale-up, adaptation to different contexts and inclusion with other online resources such as decision aids or patient education. [25][26][27] Recent research indicates they may be a particularly useful action plan format for groups with varying health literacy levels. 13,26 Despite the evidence-base underpinning implementation intentions and volitional help sheets, there is little qualitative research to T A B L E 1 Factors which INCREASE the effectiveness of implementation intentions.…”

“…[25][26][27] Recent research indicates they may be a particularly useful action plan format for groups with varying health literacy levels. 13,26 Despite the evidence-base underpinning implementation intentions and volitional help sheets, there is little qualitative research to T A B L E 1 Factors which INCREASE the effectiveness of implementation intentions.…”

“…Volitional help sheets have demonstrated effectiveness across a range of behaviours, including healthy eating, increasing physical activity and smoking cessation 15–21 . This type of plan is well suited to online formats 14,22–24 which allows for easy distribution, scale‐up, adaptation to different contexts and inclusion with other online resources such as decision aids or patient education 25–27 . Recent research indicates they may be a particularly useful action plan format for groups with varying health literacy levels 13,26 …”

Decision Support Tools for Coronary Artery Calcium Scoring in the Primary Prevention of Cardiovascular Disease Do Not Meet Health Literacy Needs: A Systematic Environmental Scan and Evaluation

“…Decision aids are effective tools to implement shared decision-making when there is not one clear option by helping people understand the clinical evidence and consider how this relates to their values [ 18 ]. In the CVD prevention context, decision aids have been shown to improve uptake and self-reported adherence to preventive interventions [ 19 ] and to improve patients’ understanding of their risk of having a CVD event [ 20 ], including those with lower health literacy [ 21 ].…”